Huang Grace, Medlam Gaylene, Lee Justin, Billingsley Susan, Bissonnette Jean-Pierre, Ringash Jolie, Kane Gabrielle, Hodgson David C
Radiation Medicine Program, Princess Margaret Hospital, University Health Network, Toronto, Ontario, Canada.
Int J Radiat Oncol Biol Phys. 2005 Apr 1;61(5):1590-5. doi: 10.1016/j.ijrobp.2004.10.017.
To examine error rates in the delivery of radiation therapy (RT), technical factors associated with RT errors, and the influence of a quality improvement intervention on the RT error rate.
We undertook a review of all RT errors that occurred at the Princess Margaret Hospital (Toronto) from January 1, 1997, to December 31, 2002. Errors were identified according to incident report forms that were completed at the time the error occurred. Error rates were calculated per patient, per treated volume (>/=1 volume per patient), and per fraction delivered. The association between tumor site and error was analyzed. Logistic regression was used to examine the association between technical factors and the risk of error.
Over the study interval, there were 555 errors among 28,136 patient treatments delivered (error rate per patient = 1.97%, 95% confidence interval [CI], 1.81-2.14%) and among 43,302 treated volumes (error rate per volume = 1.28%, 95% CI, 1.18-1.39%). The proportion of fractions with errors from July 1, 2000, to December 31, 2002, was 0.29% (95% CI, 0.27-0.32%). Patients with sarcoma or head-and-neck tumors experienced error rates significantly higher than average (5.54% and 4.58%, respectively); however, when the number of treated volumes was taken into account, the head-and-neck error rate was no longer higher than average (1.43%). The use of accessories was associated with an increased risk of error, and internal wedges were more likely to be associated with an error than external wedges (relative risk = 2.04; 95% CI, 1.11-3.77%). Eighty-seven errors (15.6%) were directly attributed to incorrect programming of the "record and verify" system. Changes to planning and treatment processes aimed at reducing errors within the head-and-neck site group produced a substantial reduction in the error rate.
Errors in the delivery of RT are uncommon and usually of little clinical significance. Patient subgroups and technical factors associated with errors can be identified. The introduction of new technology can produce new ways for errors to occur, necessitating ongoing evaluation of RT errors for quality assurance. Modifications to processes of care can produce important reductions in error rates.
研究放射治疗（RT）实施过程中的错误率、与RT错误相关的技术因素，以及质量改进干预对RT错误率的影响。
我们回顾了1997年1月1日至2002年12月31日在玛格丽特公主医院（多伦多）发生的所有RT错误。根据错误发生时填写的事件报告表来识别错误。错误率按每位患者、每个治疗体积（每位患者≥1个体积）和每次分次照射来计算。分析肿瘤部位与错误之间的关联。使用逻辑回归分析技术因素与错误风险之间的关联。
在研究期间，28136例患者接受的治疗中有555例错误（每位患者的错误率 = 1.97%，95%置信区间[CI]，1.81 - 2.14%），43302个治疗体积中有错误（每个体积的错误率 = 1.28%，95%CI，1.18 - 1.39%）。2000年7月1日至2002年12月31日有错误的分次照射比例为0.29%（95%CI，0.27 - 0.32%）。患有肉瘤或头颈部肿瘤的患者错误率显著高于平均水平（分别为5.54%和4.58%）；然而，考虑到治疗体积数量后，头颈部的错误率不再高于平均水平（1.43%）。使用附件与错误风险增加相关，内部楔形板比外部楔形板更易与错误相关（相对风险 = 2.04；95%CI，1.11 - 3.77%）。87例错误（15.6%）直接归因于“记录与验证”系统的编程错误。针对头颈部部位组减少错误而对计划和治疗流程进行的更改使错误率大幅降低。
RT实施过程中的错误并不常见，通常临床意义不大。可以识别出与错误相关的患者亚组和技术因素。新技术的引入可能产生新的错误发生方式，因此需要持续评估RT错误以进行质量保证。对护理流程的修改可显著降低错误率。
